Part 3: The Connection between Substance Use Disorders and HIV National Institute on Drug Abuse NIDA

In the nextparagraph, we review the previous studies which link HIV infection and PWID, and therelated approaches to reduce the frequency of injection behavior. The committee recommends that high priority be given to research on the estimation of the current number of IV drug users in the United States and of seroprevalence rates among different groups of IV drug users. Reviews of HIV seroprevalence studies of IV drug users show persistent associations of seroprevalence rates with geography and ethnicity (CDC, 1987a; Des Jarlais and Friedman, 1987b; Curran, 1988; Hahn et al., 1988). In the United States, there are wide variations in HIV seroprevalence by region of the country. The second set of CDC estimates of the total number of IV drug users in the United States (CDC, 1987a) indicates that more than 1 million people inject illicit drugs. National estimates of this kind are developed by aggregating estimates of the number of IV drug users in each state.

Tool to set and monitor targets for HIV prevention, diagnosis, treatment and care for key populations

The National Household Survey attempts to measure the prevalence of drug use in the general population (age 12 and older) through a household survey (see Miller et al., 1983). While this is a reasonable way to understand the scope of the problem, the method has its limitations. The sampling frame excludes persons living in transient households or in institutions (e.g., university dormitories and prisons), persons in the military, and persons with no fixed residence. Water is used to rinse out syringes and needles before they are reused—not necessarily to decontaminate the equipment but to prevent clotting and therefore unusable works. If there is no effective decontamination step (e.g., multiple rinses with a bleach solution), the use or reuse of a common rinse water supply can be a source of contamination. Integration activities took place at five other facility types described in six papers, while one paper described a multi-location macro health systems integration of HIV, substance use and other services (Table 5).

Impact of Injection and Drug Addiction

People who inject drugs are at increased risk of HIV, tuberculosis (TB), and viral hepatitis B and C (HBV and HCV), in addition to overdose. Approximately 1 in 8 (or 1.4 million) of these people are living with iv drug use HIV (UNODC World Drug Report, 2020), while 39.4% have viremic HCV infection (Grebely et al., Addiction, 2019). People who inject IV drugs are at risk for many illnesses, the most common being hepatitis and HIV.

Risk of bias assessment

• Two randomized clinical trials found that the Holistic Harm Reduction Program withbehavioral therapy reduced HIV risk behaviors and improved adherence to medical treatmentamong intravenous drug users32,33.
• Several models based on systems dynamics have been developed in the drug-use area (O’Brien, 1973; Levin et al., 1975).
• This ability to adapt to various social and market forces also sustains the belief among many users that they are not addicts but merely visitors to the heroin scene who are still in control of their lives (Fields and Walters, 1985).
• One study from the Ukraine assessed three integration models addressing substance use, HIV and TB, suggesting greater service integration increases ART access and improved patient quality of life [75].
• Across sites, 11 involved screening activities, 29 treatment integration, and nine included services for other comorbidities.

The use of nonsterile injection equipment may account for a range of infections in IV drug users, including bacterial endocarditis, hepatitis, malaria, and cellulitis or soft tissue infections (Louria et al., 1967). As the number of people with whom injection equipment is shared increases, so does the risk of HIV infection (Chaisson et al., 1987b). As with other blood-borne infections to which IV drug users are prone, HIV spreads from the infected to the uninfected user primarily by the sharing of blood-contaminated injection equipment, which serves as the vector of the virus. Three studies described integration of HIV and substance use treatment with management of other conditions, at substance use facilities. One study from the Ukraine assessed three integration models addressing substance use, HIV and TB, suggesting greater service integration increases ART access and improved patient quality of life [75]. In the USA, two studies explored primary care provision for HIV-infected drug users at substance use facilities with positive results; however, treatment paradigm differences between substance use and HIV care were reported as challenging to integration [64,66].

Study context, procedures, and population

Sociodemographic characteristics and HIV infection

Models of integration